| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Query the Registry for Juana Mariana Vazquez | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Vazquez | |
| Date of Birth | 11/01/2013 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Hospital | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/01/2013 | |
| Date/Time Administration-End | 11/01/2013 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/20/2013 | |
| Date/Time Administration-End | 12/20/2013 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/20/2014 | |
| Date/Time Administration-End | 05/20/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2015 | |
| Date/Time Administration-End | 02/21/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/21/2014 | |
| Date/Time Administration-End | 11/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/11/2015 | |
| Date/Time Administration-End | 01/11/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2014 | |
| Date/Time Administration-End | 09/25/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/29/2014 | |
| Date/Time Administration-End | 10/29/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2015 | |
| Date/Time Administration-End | 10/02/2015 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/04/2016 | |
| Date/Time Administration-End | 11/04/2016 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2014 | |
| Date/Time Administration-End | 11/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2015 | |
| Date/Time Administration-End | 05/23/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 08/22/2014 | |
| Date/Time Administration-End | 08/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2017 | |
| Date/Time Administration-End | 11/22/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Varicella virus vaccine | |
| Vaccine Administered | varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/15/2015 | |
| Date/Time Administration-End | 12/15/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 04/29/2014 | |
| Earliest Date to Give | 04/29/2014 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 04/30/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2018 | |
| Earliest Date to Give | 09/01/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/31/2017 | |
| Earliest Date to Give | 10/31/2017 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/31/2017 | |
| Earliest Date to Give | 10/31/2017 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
If the EHR does not already flag the first MMR as invalid, the provider updates the first MMR to indicate it is "invalid" as it was given too early (as notified by the registry) |
| Comments |
|---|
If the EMR already recognizes the dose as invalid, then this step may be skipped. |
| Pre-condition |
|---|
Initial Data Load - Step 2: Enter Initial Immunization Data for Juana Mariana Vazquez: Immunizations from practice |
| Post-Condition |
|---|
MMR status for the first MMR dose is set to invalid. |
| Test Objectives |
|---|
dose validity is an important aspect of: View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Evaluation Criteria: The vendor is able to record that the first MMR vaccination dose is invalid with a reason that it was given too early, and therefore the dose administered on 11/22/2017 should indicated dose '1'. |
| Notes |
|---|
In the steps that follow, the MMR returned from the registry will be imported and the vaccine forecasting steps wil further verify the correct documentation of the dose that will be imported from the registry as dose '1'. |
| Description |
|---|
The physician accesses the record for Juana Mariana Vazquez and: - Displays the registry forecast as returned by the immunization registry |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR. |
| Post-Condition |
|---|
Immunization Forecast returned from the registry has been displayed to the user. |
| Test Objectives |
|---|
View Immunization Forecast: The system provides a view of the immunization forecast provided by the public health immunization registry (IIS). The display includes the forecast from the registry and includes recommended vaccination dates, minimum (earliest) date, date due, and maximum (latest) date for each vaccine included in the forecast. |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. Verify that all forecast vaccines and dates returned by the registry are displayed to the user. |
| Notes |
|---|
The verification content for the vaccine forecast also is part of the juror document in the prior step 3: View and Compare response to request for vaccination history for Juana Mariana Vazquez. The criteria for this step is tested separately here and graded only with respect to the vaccine forecast. Date when Vaccine Overdue may be omitted for the Influenza Vaccine. For MMR, the 2nd dose is due 10/31/17 according to the schedule. Since the first one was given too early, the child is behind. Verify that the EMR shows all 3 dates returned by the registry: - Earliest Date to Give - Vaccine Due Date - Date When Vaccine Overdue |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Query the Registry for Juana Mariana Vazquez | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariana Vazquez | |
| Date of Birth | 11/01/2013 | |
| Sex | Female | |
| Address 1 | ||
| Street | 4345 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Maria Merida Acosta | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Hospital | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/01/2013 | |
| Date/Time Administration-End | 11/01/2013 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/20/2013 | |
| Date/Time Administration-End | 12/20/2013 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | hepatitis B vaccine, pediatric or pediatric/adolescent dosage | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/20/2014 | |
| Date/Time Administration-End | 05/20/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis | |
| Refusal Reason | ||
| Date/Time Administration-Start | 02/21/2015 | |
| Date/Time Administration-End | 02/21/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | ||
| Other Designation | ||
| City | ||
| State | ||
| Zip Code | ||
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Haemophilus influenzae type b vaccine, PRP-OMP conjugate | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/21/2014 | |
| Date/Time Administration-End | 11/21/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | poliovirus vaccine, inactivated | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/22/2014 | |
| Date/Time Administration-End | 05/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | pneumococcal conjugate vaccine, 13 valent | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/11/2015 | |
| Date/Time Administration-End | 01/11/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 01/22/2014 | |
| Date/Time Administration-End | 01/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | rotavirus, live, monovalent vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/23/2014 | |
| Date/Time Administration-End | 03/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/25/2014 | |
| Date/Time Administration-End | 09/25/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/29/2014 | |
| Date/Time Administration-End | 10/29/2014 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/02/2015 | |
| Date/Time Administration-End | 10/02/2015 | |
| Administered Amount | .25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza, injectable,quadrivalent, preservative free, pediatric | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/04/2016 | |
| Date/Time Administration-End | 11/04/2016 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/23/2014 | |
| Date/Time Administration-End | 11/23/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Administered | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/23/2015 | |
| Date/Time Administration-End | 05/23/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | ||
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 08/22/2014 | |
| Date/Time Administration-End | 08/22/2014 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | Sandra Molina | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 400 Shoreline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | NO | |
| Validity Reason | Early | |
| Completion Status* | Complete | |
| Dose Number in Series | ||
| Number of Doses in Series | ||
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 11/22/2017 | |
| Date/Time Administration-End | 11/22/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Varicella virus vaccine | |
| Vaccine Administered | varicella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 12/15/2015 | |
| Date/Time Administration-End | 12/15/2015 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Right Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp | |
| Administration Notes | new immunization record | |
| Administering Provider | ||
| Name | J Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 333 Oceanview Lane | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 04/29/2014 | |
| Earliest Date to Give | 04/29/2014 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 04/30/2015 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2018 | |
| Earliest Date to Give | 09/01/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/31/2017 | |
| Earliest Date to Give | 10/31/2017 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/31/2017 | |
| Earliest Date to Give | 10/31/2017 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/31/2019 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
Juana Mariana Vazquez immunization registry provided Evaluated History and Forecast is reconciled with the Immunization history information in the EMR. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariana Vazquez) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information. Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.). Support for: Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Evaluation Criteria |
|---|
1. The user imports the vaccination, date administered, and documents adverse reactions reconciled from the returned vaccinations as follows: a. Vaccinations NOT imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 12/20/2013 measles, mumps, and rubella virus vaccine (CVX 03) administered 8/22/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 11/20/2017 [known only to EMR, not available from IIS] poliovirus vaccine, inactivated (CVX 10) administered 2/21/2015 [known only to EMR, not available from IIS] b. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 11/01/2013 hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 05/20/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2014 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2015 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2014 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/21/2014 poliovirus vaccine, inactivated (CVX 10) administered 1/22/2014 poliovirus vaccine, inactivated (CVX 10) administered 3/23/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2014 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/11/2015 rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2014 rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2014 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2014 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/29/2014 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2015 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2016 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2014 hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2015 measles, mumps, rubella virus vaccine (CVX 03) administered 11/22/2017 Varicella virus vaccine (CVX 21) administered 12/15/2015 2. The tester verifies that the Reconciled Patient Immunization History can be displayed to the user. |
| Notes |
|---|
No Note |
| Description |
|---|
Once the vaccine history is reconciled in the EMR, the vaccine forecast is updated. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
EMR Vaccine History is Reconciled with Immunization History from the IIS (previous step 'Reconcile and import vaccinations from Evaluated History and Forecast returned by the Registry for Juana Mariana Vazquez'). |
| Post-Condition |
|---|
An updated vaccine forecast based upon the reconciled vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: 1. Verify that the EMR does not include in reconciled vaccine forecast: IPV due on 4/30/2014 2. Verify that the EMR includes in reconciled vaccine forecast: IPV due on 10/31/2017 Varicella due on 10/31/2017 influenza, unspecified formulation due on 09/01/2018 or later (annual recommendation - specific date may vary somewhat) |
| Notes |
|---|
The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling. Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present. |
| Description |
|---|
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariana Vazquez is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariana Vazquez Initial Data Load' |
| Post-Condition |
|---|
Visit orders are entered in Juana Mariana Vazquez' record. |
| Test Objectives |
|---|
Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record. Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details. Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Sample of data quality checking for vaccine route. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
The physician accesses the record for Juana Mariana Vazquez and: - Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine - IPV is ordered for the patient |
| Comments |
|---|
In this step, the order is recorded after receiving the alert. This step is followed by parental refusal when the administration is attempted. |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| Post-Condition |
|---|
IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures). |
| Test Objectives |
|---|
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record. |
| Evaluation Criteria | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother's refusal for IPV vaccine indicating the parent decision, the reason and documents a deferral at the time of attempted administration. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Prior Immunization History loaded and reconciled from the Immunization Registry. Order is entered for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures. |
| Post-Condition |
|---|
Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is recorded. |
| Test Objectives |
|---|
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
EMR documents the non-administration of the IPV due to the parental refusal. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions::
|
| Notes |
|---|
No Note |
| Description |
|---|
The EHR vendor loads immunization history data for an MMR dose entered 2 weeks prior to the current visit date and an MMR dose that was given too early. These MMR doses serve to seed checking for the condition that it is too early to give a live vaccine in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Orders and Immunizations, TestStep: Attempt to order Varicella Dose. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariana Vazquez. All test steps that are part of the Query the Registry for Juana Mariana test steps are completed, including the vaccination forecasting. |
| Post-Condition |
|---|
The immunization history of the MMR that was administered 2 weeks prior to the test date is loaded into the record created for Juana Mariana Vazquez. |
| Test Objectives |
|---|
Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details. Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Supporting data for: Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Notes |
|---|
The MMR doses serve to seed checking for the condition that it is too early to give a live vaccine in TestCaseGroup: Juana Mariana Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Orders and Immunizations, TestStep: Attempt to order Varicella Dose. |
| Description |
|---|
The provider attempts to give a Varicella dose, and is warned that it is too soon to give a live vaccine dose. |
| Comments |
|---|
| No Comments |
| Pre-condition |
|---|
Initial data load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. MMR dose entered at 14 days prior to the current date in TestCaseGroup: Juana Marian Vazquez Visit, TestCase: Juana Mariana Vazquez, Enter Immunization Data for MMR Given 2 Weeks Prior. |
| Post-Condition |
|---|
The provider has been issued a warning that it is too soon to give another live virus dose. |
| Test Objectives |
|---|
Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Evaluation Criteria |
|---|
There should be a warning that the attempt to give a new Varicella Dose is too early - should get warning that 28 days must pass between 2 live virus vaccines if not administered at the same time due to the prior MMR vaccination 14 days earlier. |
| Notes |
|---|
If the checking that the dose is too early is handled in the forecast logic rather than the orders interface, this is acceptable to demonstrate the capability. It can be expressed where it is not part of the recommended forecast and showing it is not 'due' or recommended until a later date. |
| Description |
|---|
The physician accesses the record for Juana Mariana Vazquez and: - Selects order for Influenza vaccine |
| Comments |
|---|
This order is a pre-condition to the following two steps related to recording the Influenza Vaccine |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. |
| Post-Condition |
|---|
Influenza order entered in patient record. |
| Test Objectives |
|---|
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. |
| Evaluation Criteria | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR records the following order information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The nurse documents administration route for the IM inactivated influenza vaccine as 'intranasal' |
| Comments |
|---|
This step covers data quality checking as an informative aspect of vaccine administration |
| Pre-condition |
|---|
Order is placed for intramuscular inactivated influenza vaccine. |
| Post-Condition |
|---|
The intramuscular, inactivated influenza vaccination route has failed to be recorded as intranasal in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria |
|---|
The EMR prevents the user from entering 'Intranasal' as a route for the the intramuscular ,inactivated influenza vaccine. |
| Notes |
|---|
No Note |
| Description |
|---|
The nurse administers the inactivated influenza vaccine |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for inactivated influenza vaccine. |
| Post-Condition |
|---|
The inactivated influenza vaccinations is recorded in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The tester Verifies that there is a choice for VFC stock as she is VFC Eligible. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:. EMR Records the following vaccine administration information:
|
| Notes |
|---|
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical). |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. The report should also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The IIS has received the vaccine information (Z22 message). |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. Notify Public Health Immunization Registry (IIS) of Update from Adverse Event: The EHR or other clinical software system notifies the public health immunization registry (IIS) of an update due to an adverse event. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. a. NDC codes, CVX for immunizations |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
Sending information updated in the EMR back to the registry is an advanced function and some registries will not accept updates. |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. the report should also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS. |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes |
|---|
Sending information updated in the EMR back to the registry is an advanced function and some registries will not accept updates. |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Vazquez |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2013 11:05 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| jmg@gmail.com | |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2014 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2014 |
| Protection Indicator | No |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Vazquez |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Phone Number |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2013 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2013 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/31/2013 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/20/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2017 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2013 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 04/22/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 05/10/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2014 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2014 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2015 |
| Administered Amount | .25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2016 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2017 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, seasonal, injectable, preservative Free |
| Date/Time Start of Administration | 10/15/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 12/30/2017 |
| Substance Manufacturer Name | GlaxoSmithKline |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | FLUARIX |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 12/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | VFC eligible-Medicaid/Medicaid Managed Care |
| Vaccine funding source | Public |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/31/2019 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella virus vaccine |
| Date/Time Start of Administration | 12/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Description |
|---|
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. This is not typically part of the user interface, so this may be demonstrated through back-end evidence. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
Following the vaccine administration, the mother reports that the patient had a rash within 14 days of dose. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The vaccinations for the visit have been administered. |
| Post-Condition |
|---|
The adverse reaction to the Influenza vaccination of rash within 14 days of dose is recorded in the EMR. |
| Test Objectives |
|---|
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. Support for: Notify Public Health Immunization Registry (IIS) of Update from Adverse Event: The EHR or other clinical software system notifies the public health immunization registry (IIS) of an update due to an adverse event. |
| Evaluation Criteria |
|---|
Verify that vendor can record the adverse reaction to the Influenza vaccination of rash within 14 days of dose correctly and without omission (VXC14). The coded value is not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions. If the vendor is unable to record the concept (VXC14) using the CDCPHINVS coding system to convey this reaction to the registry, the vendor may specify the reaction using SNOMED-CT or Narrative Text. This should be recorded as passing, but with a notable exception documented. |
| Notes |
|---|
Adverse Reactions may be documented with SNOMED-CT or as a narrative note. These two approaches may be considered passing with notable exception. The approach that is used instead of the value set PHVS_VaccinationReaction_IIS 2.16.840.1.114222.4.11.3289 should be documented in the tester notes. |
| Description |
|---|
The adverse reaction to the Influenza vaccination of rash within 14 days of dose is reported to the Immunization Registry using a Z22/VXU message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
An adverse reaction to the Influenza vaccination of rash within 14 days of dose is recorded in the EMR. |
| Post-Condition |
|---|
The adverse reaction has been transmitted to the IIS. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. Notify Public Health Immunization Registry (IIS) of Update from Adverse Event: The EHR or other clinical software system notifies the public health immunization registry (IIS) of an update due to an adverse event. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes |
|---|
The tester verifies that the message includes 'U' in RXA 21 for the Influenza vaccine. |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Vazquez |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/01/2013 11:05 |
| Administrative Sex | Female |
| Patient Address | 4345 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| jmg@gmail.com | |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 07/01/2014 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2014 |
| Protection Indicator | No |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Vazquez |
| Relationship | Grandparent |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Phone Number |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/01/2013 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 12/20/2013 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 12/31/2013 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 05/20/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 11/20/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 12/01/2017 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2013 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 11/21/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2015 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 04/22/2015 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Vaccine | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | Refused |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2014 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/11/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2015 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 05/10/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2014 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/29/2014 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2015 |
| Administered Amount | .25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2016 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 11/04/2016 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2017 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza, seasonal, injectable, preservative Free |
| Date/Time Start of Administration | 10/15/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 12/30/2017 |
| Substance Manufacturer Name | GlaxoSmithKline |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Vaccine | FLUARIX |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 12/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Update |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | VFC eligible-Medicaid/Medicaid Managed Care |
| Vaccine funding source | Public |
| Reaction | Rash within 14 days of dose |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/04/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 08/22/2014 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0853CC |
| Substance Expiration Date | 12/15/2014 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 11/22/2017 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 0854FF |
| Substance Expiration Date | 04/13/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 10/15/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 0934GG |
| Substance Expiration Date | 12/31/2019 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Vaccine | varicella virus vaccine |
| Date/Time Start of Administration | 12/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 2341BB |
| Substance Expiration Date | 12/01/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Description |
|---|
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. This is not typically part of the user interface, so this may be demonstrated through back-end evidence. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post-Condition |
|---|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. Produce Immunization Forecast Report: The EHR or other clinical software system creates a list of immunizations to be administered within a specified time frame. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post-Condition |
|---|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. Produce Immunization Forecast Report: The EHR or other clinical software system creates a list of immunizations to be administered within a specified time frame. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed Patient Identifier Number: Vendor Assigned Patient Identifier Type Code: Vendor Assigned Patient Name: Juana Mariana Vazquez Date/Time of Birth: 11/01/2013 11:05am Sex: Female Patient Address: 4345 Standish Way, Stamford, CT, 06903 Multiple Birth: N Birth Order: NA The following Vaccination History is displayed: Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 11/01/2013 Additional Observations: None Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Jane Carter Entered By: Lisa Sirtis Entering Organization: Shoreline Hospital Administered Amt: .05 mL Administering Provider: Jane Carter Administered at Location: 325 Shoreline Drive, Stamford Connecticut 06901 Lot#: 6332FK33 Exp Date: 12/14/2013 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 12/20/2013 Additional Observations: None Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 6352FK1 Exp Date: 12/31/2013 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 05/20/2014 Additional Observations: None Dose #: 3 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6352FK24 Exp Date: 8/31/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 1/22/2014 Additional Observations: None Dose #: 1 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2341 Exp Date: 11/30/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01) Date Administered: 3/23/2014 Additional Observations: None Dose #: Doses n Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2433 Exp Date: 9/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS3255 Exp Date: 12/1/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 2/21/2015 Additional Observations: Dose #: 4 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS249 Exp Date: 3/1/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 11/20/2017 Additional Observations: Dose #: 5 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Linda Casera Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D643QS8243 Exp Date: 12/01/2017 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 1/22/2013 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M54K9245 Exp Date: 3/24/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M55K3342 Exp Date: 10/30/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M75K4566 Exp Date: 5/23/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 11/21/2014 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M53K5534 Exp Date: 2/22/2015 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 1/22/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV2431 Exp Date: 10/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV4344 Exp Date: 3/23/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 2/21/2015 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D335PV9644 Exp Date: 4/22/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 1/22/2013 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P243V3281 Exp Date: 1/30/2013 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P343V8321 Exp Date: 3/30/2014 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V2164 Exp Date: 8/30/2014 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 1/11/2015 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V58532 Exp Date: 4/18/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 1/22/2014 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV533 Exp Date: 2/15/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV932 Exp Date: 5/10/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 9/25/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/29/2014 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/2/2015 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9334IN9333 Exp Date: 5/22/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 11/4/2016 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9553IN2243 Exp Date: 4/30/2017 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, seasonal, injectable, preservative Free (CVX 140) Fluvirin (NDC 66521-0118-02 ) Date Administered: 10/15/2017 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .5 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 8L4B3423| Exp Date: 12/30/2017 Manufacturer: Novartis (MVX NOV) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, seasonal, injectable, preservative Free (CVX 140) Fluvirin (66521-0118-02) Date Administered: Current Date Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .5 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 8L4B3521 Exp Date: 12/31/2019 Manufacturer: Novartis (MVX NOV) Route: Intramuscular (NCIT C28161, HL70162: IM) Site:Left Deltoid (HL7 LD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 11/23/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT33 Exp Date: 1/4/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Deltoid (HL7 RD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 5/23/2015 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT48 Exp Date: 9/11/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 08/22/2014 Additional Observations: Dose #: Doses in Series: 2 Valid Dose: N Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0853CC Exp Date: 12/15/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Thigh (HL7 LT) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (0006-4681-00)" Date Administered: 11/22/2017 Additional Observations: Invalid because it was given too soon Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0854FF Exp Date: 4/13/2018 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 14 days PRIOR to day of TEST Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS XC12) Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 0934GG Exp Date: 12/31/2019 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: Varicella Administered: Varicella vaccine (CVX 21) VarivaxI (NDC 0006-4827-00)" Date Administered: 12/15/2015 Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Martinez Entered By: Carlos Herrera Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 2341BB Exp Date: 12/1/2016 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: IPV Due Date: 10/31/2017 Earliest Date to Give: 10/31/2017 Overdue Date: 10/31/2019 Immunization Schedule: ACIP Vaccine Group: influenza, unspecified formulation Due Date: 10/21/2018 Earliest Date to Give: 9/1/2018 Immunization Schedule: ACIP Vaccine Group: varicella Due Date: 10/31/2017 Earliest Date to Give: 10/31/2017 Overdue Date: 10/31/2019 Immunization Schedule: ACIP |
| Notes |
|---|
The immunization report may provide a subset of demographic information sufficient to identify the patient. Any demographic information included should be evaluated against the listed demographic information for accuracy. The immunization report does not need to display all of the information listed in the evaluation criteria for each vaccination, but they do need to produce the complete list of vaccines given and the date. The tester is requested to document separately the success or failure of the Immunization History and the Immunization forecast as these two requirements are tested concurrently. Influenza vaccine should be due between September and October of the flue season, which may show as the prior year to testing or the year of testing. |
| Description |
|---|
Following the vaccination visit, the provider uses the EMR to produce an immunization report that can be accessed by the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) and the vaccine forecast. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| Post-Condition |
|---|
The patient/parent has been provided access to ta patient immunization history record. |
| Test Objectives |
|---|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. . |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Following the vaccination visit, the patient/parent uses the specified interface to access the immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. The parent/patient is provided with an account to access the immunization history. |
| Post-Condition |
|---|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
Provide Access to Patient Immunization Record: The EHR or other clinical software system provides patients and their authorized representatives with electronic access to immunization records (either directly or by interacting with an external system such as a patient portal). |
| Evaluation Criteria | |
|---|---|
Using the patient facing features (e.g. portal), show that the vaccine history can be displayed including today's vaccine/forecast: The following patient demographics are displayed Patient Identifier Number: Vendor Assigned Patient Identifier Type Code: Vendor Assigned Patient Name: Juana Mariana Vazquez Date/Time of Birth: 11/01/2013 11:05am Sex: Female Patient Address: 4345 Standish Way, Stamford, CT, 06903 Multiple Birth: N Birth Order: NA The following Vaccination History is displayed: Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 11/01/2013 Additional Observations: None Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Jane Carter Entered By: Lisa Sirtis Entering Organization: Shoreline Hospital Administered Amt: .05 mL Administering Provider: Jane Carter Administered at Location: 325 Shoreline Drive, Stamford Connecticut 06901 Lot#: 6332FK33 Exp Date: 12/14/2013 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 12/20/2013 Additional Observations: None Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 6352FK1 Exp Date: 12/31/2013 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hep B Peds NOS Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-11)" Date Administered: 05/20/2014 Additional Observations: None Dose #: 3 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6352FK24 Exp Date: 8/31/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 1/22/2014 Additional Observations: None Dose #: 1 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2341 Exp Date: 11/30/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01) Date Administered: 3/23/2014 Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose Dose #: Doses n Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS2433 Exp Date: 9/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS3255 Exp Date: 12/1/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 2/21/2015 Additional Observations: Dose #: 4 Doses in Series: 5 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D409QS249 Exp Date: 3/1/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) DAPTACEL (NDC 49281-0286-01)" Date Administered: 11/20/2017 Additional Observations: Dose #: 5 Doses in Series: 5 Valid Dose: Y Ordering Provider: J. Rodriguez Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .05 mL Administering Provider: Linda Casera Administered at Location: 4253 Standish Way, Stamford Connecticut 06903 Lot#: D643QS8243 Exp Date: 12/01/2017 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 1/22/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M54K9245 Exp Date: 3/24/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M55K3342 Exp Date: 10/30/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M75K4566 Exp Date: 5/23/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: Hib, unspecified formulation Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) PedvaxHIB (NDC 00006-4897-00)" Date Administered: 11/21/2014 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 7M53K5534 Exp Date: 2/22/2015 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 1/22/2014 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV2431 Exp Date: 10/4/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D333PV4344 Exp Date: 3/23/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: poliovirus vaccine, inactivated Administered: poliovirus vaccine, inactivated (CVX 10) IPOL (NDC 49281-0860-55) Date Administered: 2/21/2015 Additional Observations:
Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D335PV9644 Exp Date: 4/22/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 1/22/2013 Additional Observations: Dose #: 1 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P243V3281 Exp Date: 1/30/2013 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P343V8321 Exp Date: 3/30/2014 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 5/22/2014 Additional Observations: Dose #: 3 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V2164 Exp Date: 8/30/2014 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: pneumococcal, unspecified formulation Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133) PREVNAR 13 (NDC 00005-1971-05)" Date Administered: 1/11/2015 Additional Observations: Dose #: 4 Doses in Series: 4 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: P853V58532 Exp Date: 4/18/2015 Manufacturer: Pfizer, Inc (MVX PFR) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 1/22/2014 Additional Observations: Dose #: 1 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV533 Exp Date: 2/15/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: rotavirus, unspecified formulation Administered: rotavirus, live, monovalent vaccine (CVX 119) ROTARIX (NDC 58160-0854-52)" Date Administered: 3/23/2014 Additional Observations: Dose #: 2 Doses in Series: 3 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: 1 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RV932 Exp Date: 5/10/2014 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 9/25/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2014 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Thigh (HL7 LT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/29/2014 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D8043IN8734 Exp Date: 3/12/2015 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Thigh (HL7 RT) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 10/2/2015 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9334IN9333 Exp Date: 5/22/2016 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) FLUZONE QUADRIVALENT (NDC 49281-0514-25)" Date Administered: 11/4/2016 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .25 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: D9553IN2243 Exp Date: 4/30/2017 Manufacturer: Sanofi Pasteur Inc (MVX PMC) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, seasonal, injectable, preservative Free (CVX 140) Fluvirin (NDC 66521-0118-02) Date Administered: 10/15/2017 Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .5 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 8L4B3423| Exp Date: 12/30/2017 Manufacturer: Novartis (MVX NOV) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: influenza, unspecified formulation Administered: Influenza, seasonal, injectable, preservative Free (CVX 140) Fluvirin (66521-0118-02) Date Administered: Current Date Additional Observations: Dose #: Doses in Series: Valid Dose: Ordering Provider: Frank Smith Entered By: Sandra Molina Entering Organization: Shoreline Pediatrics Administered Amt: .5 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 8L4B3521 Exp Date: 12/31/2019 Manufacturer: Novartis (MVX NOV) Route: Intramuscular (NCIT C28161, HL70162: IM) Site:Left Deltoid (HL7 LD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 11/23/2014 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT33 Exp Date: 1/4/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Right Deltoid (HL7 RD) Vaccine Group: Hep A, unspecified formulation Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) HAVRIX (NDC 58160-0825-52)" Date Administered: 5/23/2015 Additional Observations: Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 6359RT48 Exp Date: 9/11/2015 Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB) Route: Intramuscular (NCIT C28161, HL70162: IM) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 08/22/2014 Additional Observations: Dose #: Doses in Series: 2 Valid Dose: N Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0853CC Exp Date: 12/15/2014 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Thigh (HL7 LT) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (0006-4681-00)" Date Administered: 11/22/2017 Additional Observations: Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: Carlos Herrera Entered By: J. Martinez Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 0854FF Exp Date: 4/13/2018 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: MMR Administered: measles, mumps, rubella virus vaccine (CVX 03) MMR II (NDC 0006-4681-00)" Date Administered: 14 days PRIOR to day of TEST Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS XC12) Dose #: 2 Doses in Series: 2 Valid Dose: Y Ordering Provider: Sandra Molina Entered By: Frank Smith Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: Sandra Molina Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901 Lot#: 0934GG Exp Date: 12/31/2019 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: Varicella Administered: Varicella vaccine (CVX 21) VarivaxI (NDC 0006-4827-00)" Date Administered: 12/15/2015 Dose #: 1 Doses in Series: 2 Valid Dose: Y Ordering Provider: J. Martinez Entered By: Carlos Herrera Entering Organization: Oceanview Pediatrics Administered Amt: .05 mL Administering Provider: J. Martinez Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901 Lot#: 2341BB Exp Date: 12/1/2016 Manufacturer: Merck Sharp & Dohme Corp (MVX MSD) Route: Subcutaneous (NCIT C38299, HL70162: SC) Site: Left Deltoid (HL7 LD) Vaccine Group: IPV Due Date: 10/31/2017 Earliest Date to Give: 10/31/2017 Overdue Date: 10/31/2019 Immunization Schedule: ACIP Vaccine Group: influenza, unspecified formulation Due Date: 10/21/2018 Earliest Date to Give: 9/1/2018 Immunization Schedule: ACIP Vaccine Group: varicella Due Date: 10/31/2017 Earliest Date to Give: 10/31/2017 Overdue Date: 10/31/2019 Immunization Schedule: ACIP |
| Notes |
|---|
If the same immunization report verified in TestCase 4 for Juana Mariana Vazquez is used for the patient access to the immunization record, then content verification does not need to be repeated. Influenza vaccine should be due between September and October of the flu season, which may show as the prior year to testing or the year of testing. |
| Description |
|---|
| Comments |
|---|
| Pre-condition |
|---|
| Post-Condition |
|---|
| Test Objectives |
|---|
| Evaluation Criteria |
|---|
| Notes |
|---|
| Description |
|---|
The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juan Marcel Marina. Querying the registry will consist of the vendor creating Z44 messages for Juan Marcel Marina to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. Using the Z42 Response to Immunization Registry Query, the EMR displays the Evaluated History and Forecast to the user for reconciliation and update. The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juan Marcel Marina is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juan Marcel Marina Initial Data Load' |
| Post-Condition |
|---|
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned . |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.). Support for: Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Juan Marcel Marina is selected as the patient and his record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juan Marcel Marina Initial Data Load completed. |
| Post-Condition |
|---|
Juan Marcel Marina is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Juan Marcel Gonzales from similar sounding names using all of the pediatric demographics:
|
| Notes |
|---|
No Note |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juan Marcel Marina Initial Data Load is completed. Juan Marcel Marina is the active working patient in the EMR. |
| Post-Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juan Marcel Marina. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Marina |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 03/04/2017 11:00 |
| Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1213 |
| Birth Indicator | No |
| Birth Order |
| Description |
|---|
The physician accesses the record for Juan Marcel Marina and: - Accepts the vaccines provided by the registry as this is a new patient and there are no prior vaccines recorded |
| Comments |
|---|
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juan Marcel Marina) |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Compare Public Health Immunization Registry (IIS) Immunization History to EHR Immunization History: The public health immunization registry has returned the requested immunization history for a patient. The EHR is able to display the immunization history received from the registry as well as the immunization history already present in the EHR so that a user can compare them. The EHR provides a way for the provider to view both histories, determine what is different (if anything), and update the existing EHR immunization history with new information from the public health registry if he or she chooses to do so. The system must store the new information as structured data as part of the patient's local immunization history and include the time of the update and the source of the new information. Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.). Supporting data for: Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports returned vaccinations as follows using only the vaccination, and administration dates returned from the Immunization Registry:a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 3/3/2017 hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 4/15/2017 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/15/2017diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 7/13/2017 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/16/2017 diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 9/20/2018 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/14/2017 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 7/21/2017 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 9/27/2017 Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/4/2018 poliovirus vaccine, inactivated (CVX 10) administered 5/14/2017 poliovirus vaccine, inactivated (CVX 10) administered 7/21/2017 poliovirus vaccine, inactivated (CVX 10) administered 10/15/2017 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 7/21/2017 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 9/27/2017 pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/4/2018 rotavirus, live, monovalent vaccine (CVX 119) administered 5/18/2017 rotavirus, live, monovalent vaccine (CVX 119) administered 7/21/2017 Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/20/2018 measles, mumps, rubella virus vaccine (CVX 03) administered 6/20/2018 |
| Notes |
|---|
The EMR must minimally display the vaccine administered and the date of the immunization. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Query the Registry for Juan Marcel Marina | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juan Marcel Marina | |
| Date of Birth | 03/04/2017 | |
| Sex | Male | |
| Address 1 | ||
| Street | 4623 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Anita Francesca Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Shoreline Hospital | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 03/04/2017 | |
| Date/Time Administration-End | 03/04/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 325 Shorline Drive | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06901 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | hepatitis B vaccine, unspecified formulation | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 04/15/2017 | |
| Date/Time Administration-End | 04/15/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/15/2017 | |
| Date/Time Administration-End | 05/15/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/13/2017 | |
| Date/Time Administration-End | 07/13/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/16/2017 | |
| Date/Time Administration-End | 09/16/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified | |
| Vaccine Administered | DTaP | |
| Refusal Reason | ||
| Date/Time Administration-Start | 08/20/2018 | |
| Date/Time Administration-End | 08/20/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Sanofi Pasteur Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 5 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2017 | |
| Date/Time Administration-End | 05/14/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2017 | |
| Date/Time Administration-End | 07/21/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2017 | |
| Date/Time Administration-End | 09/27/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | Hib, unspecified formulation | |
| Vaccine Administered | Hib | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2018 | |
| Date/Time Administration-End | 05/04/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/14/2017 | |
| Date/Time Administration-End | 05/14/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | poliovirus vaccine, inactivated | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2017 | |
| Date/Time Administration-End | 07/21/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Polio (IPV) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/15/2017 | |
| Date/Time Administration-End | 10/15/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | MSanofi Pasteur Inc. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2017 | |
| Date/Time Administration-End | 05/18/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 07/21/2017 | |
| Date/Time Administration-End | 07/21/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2017 | |
| Date/Time Administration-End | 09/27/2017 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 3 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | pneumococcal, unspecified formulation | |
| Vaccine Administered | Pneumococcal conjugate (PCV13) | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/04/2018 | |
| Date/Time Administration-End | 05/04/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Deltoid | |
| Substance Manufacturer Name | Pfizer, Inc | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 4 | |
| Number of Doses in Series | 4 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 05/18/2017 | |
| Date/Time Administration-End | 05/18/2017 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Administered | Rotavirus | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/21/2017 | |
| Date/Time Administration-End | 09/21/2017 | |
| Administered Amount | 1.0 | |
| Administered Units of Measure | mL | |
| Route of Administration | Oral | |
| Administration Site | Thigh Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 09/27/2017 | |
| Date/Time Administration-End | 09/27/2017 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Administered | Influenza | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/20/2017 | |
| Date/Time Administration-End | 10/20/2017 | |
| Administered Amount | 0.25 | |
| Administered Units of Measure | mL | |
| Route of Administration | Intramuscular | |
| Administration Site | Right Thigh | |
| Substance Manufacturer Name | Sanofi Pasteur | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 2 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| Element Name | Data | Tester Comment |
| Entering Organization | Oceanview Pediatrics | |
| Vaccine Group | MMR | |
| Vaccine Administered | measles, mumps, rubella virus vaccine | |
| Refusal Reason | ||
| Date/Time Administration-Start | 06/20/2018 | |
| Date/Time Administration-End | 06/20/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | Subcutaneous | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. | |
| Administration Notes | ||
| Administering Provider | ||
| Name | J. Martinez | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 4253 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 2 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 08/31/2017 | |
| Earliest Date to Give | 08/31/2017 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 09/01/2018 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2018 | |
| Earliest Date to Give | 03/04/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | ||
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 03/04/2018 | |
| Earliest Date to Give | 03/04/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | ||
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep A, pediatric, unspecified formulation | |
| Vaccine Due Date | 03/04/2018 | |
| Earliest Date to Give | 03/04/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | ||
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
The physician accesses the record for Juan Marcel Marina and, once the vaccine history is reconciled in the EMR, the vaccine forecast is updated. - The provider views the updated vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
The vaccine forecast may be imported from the Immunization Registry Vaccination History and Forecast (Z42) response, or it may be generated by EMR defined means. |
| Pre-condition |
|---|
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juan Marcel Gonzales) |
| Post-Condition |
|---|
A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 8/31/2017 influenza, unspecified formulation due on Sep 1, 2018 or later (annual recommendation - specific date may vary somewhat) In support of test objective 'Modify Antigen Recommendations Based on Active Diagnoses' the tester verifies that the system notifies the provider that: 1. Varicella due on 3/4/2018 - Forecast should not show that they need vaccine for Varicella; because of known diagnosis that this is due. 2. Hep A is due 3/4/2018 - Forecast may not show that they need the vaccine for Hepatitis A due to serologic immunity to the disease. |
| Notes |
|---|
The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling. Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present.
|
| Description |
|---|
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juan Marcel Marina is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juan Marcel Marina Initial Data Load' |
| Post-Condition |
|---|
Visit orders are entered in Juan Marcel Marina's record. |
| Test Objectives |
|---|
Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses. Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired. Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
As indicated by the vaccine forecast, the third Hepatitis B is overdue, and is ordered. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast reviewed. |
| Post-Condition |
|---|
Hepatitis B vaccine is ordered for the patient. |
| Test Objectives |
|---|
Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. |
| Evaluation Criteria | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information:. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The fifth DTaP is ordered, and the provider is notified that the dose is too early. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast is available in the EMR. |
| Post-Condition |
|---|
DTaP vaccine is ordered for the patient, and provider is notified that the dose is too early. |
| Test Objectives |
|---|
Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required. Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines. |
| Evaluation Criteria | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The nurse documents administration route for the HepB vaccine |
| Comments |
|---|
This step covers data quality checking as an informative aspect of vaccine administration |
| Pre-condition |
|---|
Order is placed for HepB vaccine. |
| Post-Condition |
|---|
The HepB vaccination route has failed to be recorded as 'oral' in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria |
|---|
The EMR prevents the user for entering 'Oral' as a route for the the HepB vaccine. |
| Notes |
|---|
No Note |
| Description |
|---|
The nurse documents administration lot number for the Hepatitis B vaccine |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for Hepatitis B vaccine. |
| Post-Condition |
|---|
The provider has been notified of the expired Hepatitis B vaccination lot. Documentation of a lot to be administered that is not expired is recorded in the EMR. |
| Test Objectives |
|---|
Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired. |
| Evaluation Criteria | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following order information and Alert. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The nurse administers the the Hepatitis B vaccine |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for Hepatitis B vaccine. |
| Post-Condition |
|---|
The Hepatitis B vaccination is recorded in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical). |
| Description |
|---|
The nurse documents administration for the inactivated influenza vaccine from a VFC source |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for inactivated influenza vaccine. |
| Post-Condition |
|---|
The user is notified of vaccine dose ineligibility. |
| Test Objectives |
|---|
Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected. |
| Evaluation Criteria | ||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The provider documents a VFC lot to be administered in the EMR. Once notified that the patient is not eligible for the VFC, then a non-VFC lot is selected. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
The Provider selects a non-VFC Lot:
|
| Notes |
|---|
No Note |
| Description |
|---|
The nurse administers the inactivated influenza vaccine |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for inactivated influenza vaccine. |
| Post-Condition |
|---|
The inactivated influenza vaccine administration is recorded in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical). |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The IIS has received the vaccine information (Z22 message). |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines, and an indication that Varicella was not administered due to a history of the disease as evidence of immunity. The Vaccination report also includes an indication that Hepatitis A was not administered due to serological evidence of immunity. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS. |
| Pre-condition |
|---|
The vaccines for the visit have been administered. The clinical information has been documented for Juan Marcel Marina in the Initial Data Load. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. This includes indication that Varicella was not administered due to history of the disease, and an indication that Hepatitis A was not administered due to serological evidence of immunity. |
| Notes |
|---|
This message has been updated in the 2018 release to indicate that no Varicella vaccine was administered due to a history of the illness as evidence of immunity. This message has also been updated in the 2018 release to indicate that no Hepatitis A vaccine was administered due to serological evidence of immunity. These are not subject to the 90% rule in this introductory year. Tester should document any issues with these new evaluation stage test features. |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Marina |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/04/2017 11:00 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 03/04/2017 |
| Publicity Code | Reminder/recall - no calls |
| Publicity Code Effective Date | 03/04/2017 |
| Protection Indicator | No |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 03/04/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2017 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 04/15/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2017 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | ENGERIX-B |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Date vaccine information statement published | 07/15/2015 |
| Date vaccine information statement presented | 10/31/2018 |
| vaccine type | Hepatitis B |
| vaccine fund pgm elig cat | Not VFC elig |
| Vaccine funding source | Private |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 05/15/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2018 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 07/13/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2017 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 09/16/2016 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 12/01/2017 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP |
| Date/Time Start of Administration | 08/20/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 03/01/2019 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/14/2016 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 07/21/2016 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2017 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 09/27/2016 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 05/04/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 10/14/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 05/14/2016 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 10/04/2017 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 07/21/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2018 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Polio (IPV) |
| Date/Time Start of Administration | 10/15/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 02/22/2018 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/18/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2018 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 07/21/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2018 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 09/27/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2018 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/04/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2018 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 05/18/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 10/29/2017 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Rotavirus |
| Date/Time Start of Administration | 09/21/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2018 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 09/27/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2018 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | Influenza |
| Date/Time Start of Administration | 10/20/2017 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 05/22/2018 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | FLUZONE QUADRIVALENT |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | Not VFC elig |
| Vaccine funding source | Private |
| Element | Data |
|---|---|
| Administered Vaccine | measles, mumps, rubella virus vaccine |
| Date/Time Start of Administration | 06/20/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2018 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Vaccine | varicella |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Disease with presumed immunity | History of Varicella infection |
| Element | Data |
|---|---|
| Administered Vaccine | Hep A, pediatric, unspecified formulation |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Diseases with serological evidence of immunity | Serology confirmed hepatitis A |
| Description |
|---|
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
The provider identifies that the vaccine administration of Hepatitis B for this visit was documented in error. The vaccine was not administered during the visit as the provider had received notification that the Hepatitis B vaccine lot 332FK26 had been identified as a bad lot, and no other lot was available from inventory. A delete notification for the Hepatitis B vaccination administered is transmitted to the Immunization Registry for Juan Marcel Marina. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The vaccinations for the visit have been administered. . |
| Post-Condition |
|---|
The EMR has recorded that the hepatitis B vaccination was from a bad lot. Juan Marcel Marina's record is updated to reflect that the immunization given with lot 6332FK26 is invalid. The Delete notification for this vaccination has been transmitted to the Immunization Registry. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. Support for delete functionality. |
| Evaluation Criteria |
|---|
Verify that EMR can record the bad lot. Verify that the vaccination record for Juan Marcel Marina for the Hepatitis B vaccination given with lot 6332FK26 is marked as invalid. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/04/2017 11:00 |
| Administrative Sex | Male |
| Patient Address | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | No |
| Birth Order |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Delete |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| vaccine fund pgm elig cat | Not VFC elig |
| vaccine type | Hepatitis B |
| Date vaccine information statement published | 07/15/2015 |
| Date vaccine information statement presented | 10/31/2018 |
| Description |
|---|
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message. |
| Comments |
|---|
| No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
| Comments |
|---|
| Pre-condition |
|---|
| Post-Condition |
|---|
| Test Objectives |
|---|
| Evaluation Criteria |
|---|
| Notes |
|---|
| Description |
|---|
The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Mariela Gonzales. Querying the registry will consist of the vendor creating Z44 messages for Juana Mariela Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. Using the Z42 Response to Immunization Registry Query, the EMR displays the Evaluated History and Forecast to the user for reconciliation and update. The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the Juana Mariela Gonzales Initial Data Load' |
| Post-Condition |
|---|
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Juana Mariela Gonzales is selected as the patient and her record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariela Gonzales Initial Data Load completed. |
| Post-Condition |
|---|
Juana Mariela Gonzales is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Juana Mariela Gonzales Morales from similar sounding names and her twin using all of the pediatric demographics:
|
| Notes |
|---|
Patient last name from the hospital returned by the IIS is Morales (the mother's maiden name). The patient last name in the EMR should be Gonzales. This test verifies that the EMR can match the returned record despite the different last name. |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariela Gonzales Initial Data Load is completed. Juana Mariela Gonzales is the active working patient in the EMR. |
| Post-Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Mariela Gonzales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariela Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | |
| Date/Time of Birth | 10/01/2018 11:00 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | No |
| Birth Order |
| Description |
|---|
The physician accesses the record for Juana Mariela Gonzales and: - Accepts the single vaccine in the registry record into the EHR history |
| Comments |
|---|
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Mariela Gonzales) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports returned vaccinations as follows: a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 10/1/2018 |
| Notes | |||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
If the EMR is unable to match and import the previous immunization record, they will need to add the following historical immunization manually:
|
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Query the Registry for Juana Mariela Gonzales | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | Juana Mariela Gonzales | |
| Date of Birth | 10/01/2018 | |
| Sex | Female | |
| Address 1 | ||
| Street | 3321 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Joanna Elena Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Stamford Regional Hospital | |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/01/2018 | |
| Date/Time Administration-End | 10/01/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | Susan Pike | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 15 Atlantic Avenue | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 10/31/2018 | |
| Earliest Date to Give | 10/31/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 12/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hib | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Pneumococcal Conjugate, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2019 | |
| Earliest Date to Give | 09/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 01/01/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 01/01/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
The physician accesses the record for Juana Mariela Gonzales and: - Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Mariela Gonzales) |
| Post-Condition |
|---|
A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 10/31/2018 DTaP due on 11/30/2018 Hib due on 11/30/2018 Pneumococcal conjugate due on 11/30/2018 Rotavirus due on 11/30/2018 HepA due on 10/1/2019 MMR due on 10/1/2019 Varicella due on 10/1/2019 influenza, unspecified formulation due on Sept 1, 2019 or later |
| Notes |
|---|
The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling. Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present. |
| Description |
|---|
This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Mariela Gonzales Initial Data Load' |
| Post-Condition |
|---|
Visit orders are entered in Juana Mariela Gonzales' record. |
| Test Objectives |
|---|
Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule) Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses. Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
The triage nurse enters basic information on Juana Mariela Gonzales - she has a fever (Temperature of 100.8o F). |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The EMR has recorded all of the pediatric demographic data in the record created for Juana Mariela Gonzales. |
| Post-Condition |
|---|
The clinical record for Juana Mariela Gonzales indicates that she currently has a fever (temperature 100.8oF). |
| Test Objectives |
|---|
Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule): Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient's current or historical diagnoses. |
| Evaluation Criteria | ||||||||
|---|---|---|---|---|---|---|---|---|
Evaluation Criteria: Vendor successfully records all clinical data provided with all required attributes indicated by [Y]. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
No Note |
| Description |
|---|
The physician accesses the record for Juana Mariela Gonzales Morales and: |
| Comments |
|---|
No Comment |
| Pre-condition |
|---|
Prior Immunization History loaded and reconciled from the Immunization Registry. Vaccine forecast is available in the EMR indicating 5 vaccines are due: Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus |
| Post-Condition |
|---|
Vaccine deferral is recorded indicating the medical reason of low grade fever |
| Test Objectives |
|---|
Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.). The system also stores that information in a structured way so it can be reported and analyzed as needed. |
| Evaluation Criteria | ||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical). |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes deferrals for the vaccines that were due this visit indicating the medical reason. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
The vaccines for the visit have been deferred. |
| Post-Condition |
|---|
The IIS has received the vaccine information (Z22 message). |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariela Gonzales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2018 11:00 |
| Administrative Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1212 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | Yes |
| Birth Order | 1 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2018 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 12/01/2018 |
| Vaccination temporary contraindication/precaution expiration date | 01/01/2018 |
| Element | Data |
|---|---|
| Administered Vaccine | DTaP, unspecified formulation |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 12/01/2018 |
| Vaccination temporary contraindication/precaution expiration date | 01/01/2018 |
| Element | Data |
|---|---|
| Administered Vaccine | Hib |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 12/01/2018 |
| Vaccination temporary contraindication/precaution expiration date | 01/01/2018 |
| Element | Data |
|---|---|
| Administered Vaccine | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 12/01/2018 |
| Vaccination temporary contraindication/precaution expiration date | 01/01/2018 |
| Element | Data |
|---|---|
| Administered Vaccine | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | Not Administered |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 12/01/2018 |
| Vaccination temporary contraindication/precaution expiration date | 01/01/2018 |
| Description |
|---|
The Immunization Registry returns a positive acknowledgement message indicating that no errors were found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
No Test Objectives |
| Evaluation Criteria |
|---|
The acknowledgement message is consumed by the system responsible for the content of the administration message without error. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
| Comments |
|---|
| Pre-condition |
|---|
| Post-Condition |
|---|
| Test Objectives |
|---|
| Evaluation Criteria |
|---|
| Notes |
|---|
| Description |
|---|
The EMR Generates a Z44 query to the Immunization Registry to retrieve the Evaluated History and Forecast for Juana Maria Gonzales. Querying the registry will consist of the vendor creating Z44 messages for Juana Maria Gonzales to be sent to the registry. The response will be processed as part of the 'Display, Reconcile, Import and Update Immunization Information' activity. Using the Z42 Response to Immunization Registry Query, the EMR displays the Evaluated History and Forecast to the user for reconciliation and update. The vendor will receive information back from the registry and show the ability to view and reconcile, and import the information returned by the registry (NOTE: the Z42 message will be provided either manually, or as part of the tool). This test will also look at the system's ability to view the forecast returned by the registry, and create a new forecast after reconciling the information. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Mariela Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the Juana Mariela Gonzales Initial Data Load |
| Post-Condition |
|---|
A Z44 Query is generated and submitted to the Immunization Registry/Test tool, and a Z42 response is returned. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
Juana Maria Gonzales is selected as the patient and her record is opened in the EMR. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Juana Maria Gonzales Initial Data Load completed. |
| Post-Condition |
|---|
Juana Maria Gonzales is the active working patient in the EMR. |
| Test Objectives |
|---|
Select New Patient: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information. For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother's maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient's information to external systems such as an immunization registry. |
| Evaluation Criteria |
|---|
Tester shall verify that the product can distinguish Juana Maria Gonzales from similar sounding names and her twin using all of the pediatric demographics:
|
| Notes |
|---|
No Note |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. This query will result in an error that too many matches are found. |
| Comments |
|---|
While the query is identical, the response to this step will be that no persons are found. No demographic changes are requested for this step as the error trigger is specific to the test step. |
| Pre-condition |
|---|
Juana Maria Gonzales Initial Data Load is completed. Juana Maria Gonzales is the active working patient in the EMR. |
| Post-Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Setup step to test error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user. |
| Evaluation Criteria |
|---|
Tester shall verify that the vendor can produce a valid Z44 query in accordance with the test data correctly and without omission. Tester shall verify that the data in the message corresponds to the data in the EMR and contains all test data attributes supplied. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 2 |
| Description |
|---|
The EMR processes notifies the user that there were too many matches found in response to the query the Immunization Registry for an Evaluated History and Forecast. |
| Comments |
|---|
The sending (querying) system will need to accept a response indicating that too many matches were found. |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
The Immunization Registry responds with a message is indicating too many matches are found. The EMR has notified the user. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Tests error handling: Test the capability of the EHR-S to process a response message that returns too many matches found and to provide an indication to the end user. |
| Evaluation Criteria |
|---|
The tester verifies that the user/clinician is notified of no match. The EHR shall display a notification indicating that the query for an Evaluated Immunization History and Immunization Forecast is complete but too many matching records were found for the person in the query. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. This query will result in an error that no persons are found. |
| Comments |
|---|
This step is a repeat of Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales in order to set up the error-checking response for 'No Persons Found'. While the query is identical, the response to this step will be that no persons are found. No demographic changes are requested for this step as the error trigger is specific to the test step. |
| Pre-condition |
|---|
Juana Maria Gonzales Initial Data Load is completed. Juana Maria Gonzales is the active working patient in the EMR. |
| Post-Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Tests error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user. |
| Evaluation Criteria |
|---|
Tester verifies that the message has been created and submitted in the test plan to trigger the error handling response in the next step. |
| Notes |
|---|
Query step is the same as Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales. No new requirements tested |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 2 |
| Description |
|---|
The EMR processes notifies the user that there were no persons found in response to the query the Immunization Registry for an Evaluated History and Forecast. |
| Comments |
|---|
The sending (querying) system will need to accept a response indicating that no matches were found. |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
The Immunization Registry responds with a message is indicating no person record is found. The EMR has notified the user. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Tests error handling: Test the capability of the EHR-S to process a response message that returns no persons found and to provide an indication to the end user. |
| Evaluation Criteria |
|---|
The tester verifies that the user/clinician is notified of no match. The EHR shall display a notification indicating that the query for an Evaluated Immunization History and Immunization Forecast is complete but no matching records were found for the person in the query. |
| Notes |
|---|
No Note |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
The provider uses the EMR to query the Immunization Registry for an Evaluated History and Forecast based on information known to the Immunization Registry. |
| Comments |
|---|
This step is a repeat of Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales in order to set up the response for the history and forecast that will be imported in the following step. |
| Pre-condition |
|---|
Juana Maria Gonzales Initial Data Load is completed. Juana Maria Gonzales is the active working patient in the EMR. |
| Post-Condition |
|---|
The Immunization Registry responds with Evaluated Vaccine History and Forecast for Juana Maria Gonzales. |
| Test Objectives |
|---|
Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (QBP/RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. |
| Evaluation Criteria |
|---|
Tester verifies that the message has been created and submitted in the test plan to trigger the error handling response in the next step. |
| Notes |
|---|
Query step is the same as Step 2: Query Registry for vaccination history and forecast for Juana Maria Gonzales . No new requirements tested |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Morales |
| ID Number | 123456 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Sex | Female |
| Patient Address | 3321 Standish Way Stamford CT 06903 |
| Patient Phone | (203)555-1214 |
| Birth Indicator | Yes |
| Birth Order | 2 |
| Description |
|---|
The physician accesses the record for Juana Maria Gonzales and: - Accepts the single vaccine in the registry record into the EHR history |
| Comments |
|---|
There is no reconciliation step as there are no historical immunizations in the EMR. All will be imported from the Z42 response. |
| Pre-condition |
|---|
A Z44 query has been submitted to the Immunization Registry and a Z42 response is provided back to the EMR.and the response is available in the EMR for reconciliation and import. |
| Post-Condition |
|---|
Evaluated Immunization History returned from the registry is reconciled and imported into the patient record (Juana Maria Gonzales) |
| Test Objectives |
|---|
Request/Receive Patient Immunization Data and Identify Source: The EHR or other clinical software is able to store immunization history accepted electronically from other sources (such as a public health immunization registry consistent with HL7 version 2.5.1, Implementation Guide for Immunization Messaging Release 1.5) or communicated by the patient and manually entered by the clinician. When viewing such information, the provider can determine which immunizations were administered by the practice, which were entered manually as patient-reported, and which were accepted electronically from the public health registry. Real Time Request/Receive Patient Immunization History: The system sends a request to the public health immunization registry "on demand" (e.g., those without scheduled appointments). The request includes the identifying information the immunization registry needs to match each patient with those in the registry including, if present, the mother's maiden name, a multiple birth indicator, and the birth order. The request also is sent in a pre-determined format the registry can read and interpret (Query Response Grammar (RSP) - HL7 version 2.5.1 Implementation Guide for Immunization Messaging Release 1.5). |
| Evaluation Criteria |
|---|
1. The EMR displays the information returned from the Immunization Registry according to the Juror Document. 2. The user imports the vaccination given and the date administered returned from the immunization registry as follows: a. Vaccinations Imported: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) administered 10/1/2018 |
| Notes | |||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The message returns 'BG2' in the first name of the patient as the first immunization was given at the time of birth before the patient's first name was selected. The EMR should be able to import this record into the patient record despite the apparent name mismatch retaining the original name, Juana Maria Gonzales. If the EMR is unable to match and import the previous immunization record, they will need to add the following historical immunization manually. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Evaluated Immunization History and Immunization Forecast | |||||
|---|---|---|---|---|---|
| Test Case ID | Query the Registry for Juana Maria Gonzales. | ||||
| Juror ID | |||||
| Juror Name | |||||
| HIT System Tested | |||||
| Inspection Date/Time | |||||
| Inspection Settlement (Pass/Fail) |
|
||||
| Reason Failed | |||||
| Juror Comments | |||||
This Test Case-specific Juror Document provides a checklist for the Tester to use during certification testing for assessing the EHR technology's ability to display required core data elements from the information received in the Evaluated Immunization History and Immunization Forecast Z42 response message. Additional data from the message or from the EHR are permitted to be displayed by the EHR. Grayed-out fields in the Juror Document indicate where no data for the data element indicated were included in the Z42 message for the given Test Case.
The format of this Juror Document is for ease-of-use by the Tester and does not indicate how the EHR display must be designed.
The Evaluated Immunization History and Immunization Forecast data shown in this Juror Document are derived from the Z42 message provided with the given Test Case; equivalent data are permitted to be displayed by the EHR. The column headings are meant to convey the kind of data to be displayed; equivalent labels/column headings are permitted to be displayed by the EHR.
| Patient Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Patient Identifier | ||
| ID Number | 123456 | |
| Assigning Authority | ||
| Namespace ID | MYEHR | |
| ID Type | MR | |
| Patient Identifier | ||
| ID Number | 987633 | |
| Assigning Authority | ||
| Namespace ID | MYIIS | |
| ID Type | SR | |
| Name | BG2 Morales | |
| Date of Birth | 10/01/2018 | |
| Sex | Female | |
| Address 1 | ||
| Street | 3321 Standish Way | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | USA | |
| Address Type | L | |
| Mother's Maiden Name | Joanna Elena Morales | |
| When displayed in the EHR with the Evaluated Immunization History and Immunization Forecast, these patient demographics data may be derived from either the received immunization message or the EHR patient record. When displaying demographics from the patient record, the EHR must be able to demonstrate a linkage between the demographics in the message (primarily the patient ID in PID-3.1) and the patient record used for display to ensure that the message was associated with the appropriate patient. | ||
| Evaluated Immunization History Information | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Entering Organization | Stamford Regional Hospital | |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Administered | Hepatitis B | |
| Refusal Reason | ||
| Date/Time Administration-Start | 10/01/2018 | |
| Date/Time Administration-End | 10/01/2018 | |
| Administered Amount | 0.5 | |
| Administered Units of Measure | mL | |
| Route of Administration | IM | |
| Administration Site | Left Thigh | |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA | |
| Administration Notes | ||
| Administering Provider | ||
| Name | Susan Pike | |
| ID Number | ||
| Administered-at Location | ||
| Facility ID | DCS_DC | |
| Street Address | 15 Atlantic Avenue | |
| Other Designation | ||
| City | Stamford | |
| State | CT | |
| Zip Code | 06903 | |
| Country | ||
| Valid Dose | YES | |
| Validity Reason | ||
| Completion Status* | Complete | |
| Dose Number in Series | 1 | |
| Number of Doses in Series | 3 | |
| Immunization Series Name | ||
| Status in Immunization Series | ||
| Immunization Schedule Used | ACIP | |
| * "Completion Status" refers to the status of the dose of vaccine administered on the indicated date and may be interpreted as "Dose Status". A status of "Complete" means that the vaccine dose was "completely administered" as opposed to "partially administered". | ||
| Immunization Forecast | ||
|---|---|---|
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep B, unspecified formulation | |
| Vaccine Due Date | 10/31/2018 | |
| Earliest Date to Give | 10/31/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 12/01/2017 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | DTaP, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hib | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | IPV | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Pneumococcal Conjugate, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | rotavirus, unspecified formulation | |
| Vaccine Due Date | 11/30/2018 | |
| Earliest Date to Give | 11/30/2018 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | influenza, unspecified formulation | |
| Vaccine Due Date | 09/01/2019 | |
| Earliest Date to Give | 09/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Hep A, unspecified formulation | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 10/02/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | MMR | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 01/01/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Element Name | Data | Tester Comment |
| Vaccine Group | Varicella | |
| Vaccine Due Date | 10/01/2019 | |
| Earliest Date to Give | 10/01/2019 | |
| Latest Date to Give | ||
| Date When Vaccine Overdue | 01/01/2020 | |
| Status in Immunization Series | ||
| Forecast Reason | ||
| Description |
|---|
The physician accesses the record for Juana Maria Gonzales and: - Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods) |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Maria Gonzales) |
| Post-Condition |
|---|
A vaccine forecast based upon the imported vaccine history is available to the user. |
| Test Objectives |
|---|
View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient's newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service. |
| Evaluation Criteria |
|---|
1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history: Hep B Peds NOS due on 10/31/2018 DTaP due on 11/30/2018 Hib due on 11/30/2018 Pneumococcal conjugate due on 11/30/2018 Rotavirus due on 11/30/2018 HepA due on 10/1/2019 MMR due on 10/1/2019 Varicella due on 10/1/2019 |
| Notes |
|---|
The due date must be in range for the date shown. Vaccine forecast dates may be plus or minus 10 days to accommodate differences in date handling. Further variation should be documented in the notable exceptions, but minimally each forecast vaccine must be present. |
| Description |
|---|
| This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. |
| Comments |
|---|
| No Comments |
| Pre-condition |
|---|
| Juana Maria Gonzales is entered as a patient in the EMR with complete Demographic data, Immunization History Data, and Clinical Data according to the steps in the 'Juana Maria Gonzales Initial Data Load' |
| Post-Condition |
|---|
| Visit orders are entered in Juana Maria Gonzales' record. |
| Test Objectives |
|---|
Supporting data for error handling tests. |
| Evaluation Criteria |
|---|
| Evaluation criteria is defined within each test step. |
| Notes |
|---|
| No Note |
| Description |
|---|
The nurse administers the the DTaP-hepatitis B and poliovirus vaccine |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Order is placed for DTaP-hepatitis B and poliovirus vaccine. |
| Post-Condition |
|---|
The DTaP-hepatitis B and poliovirus vaccination is recorded in the EMR. |
| Test Objectives |
|---|
Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered. The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
EMR Records the following vaccine administration information. The coded values are not expected to be displayed to the user, but it is expected that the value selected has the identified meaning, and it is expected that the system will use the coded value when the attribute is conveyed in later transactions:
|
| Notes |
|---|
The EMR does not need to specify a 'new immunization', as long as there is a way to indicate that it is a new immunization within the EMR, this is acceptable (e.g. the default interpretation of the data entry is that it is a new immunization and not historical). |
| Description |
|---|
| Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS. This transaction will result in an error or warning from the IIS. |
| Comments |
|---|
| No Comments |
| Pre-condition |
|---|
| The vaccines for the visit have been administered. |
| Post-Condition |
|---|
| The
IIS has received the vaccine information (Z22 message) and issued a Z23 response with an error or warning. |
| Test Objectives |
|---|
| Transmit Standard Patient Immunization History
Report: The EHR or other clinical software system directly
or indirectly through an intermediary creates and transmits a report of a
patient's immunization history to public health immunization registries. Verify that the EMR is able to receive and display the error or warning response from the IIS. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. a. NDC codes, CVX for immunizations |
| Evaluation Criteria |
|---|
| Evaluation criteria is defined within each test step. |
| Notes |
|---|
| No Note |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The report MAY send the immunizations that the EMR imported from the IIS. This will result in a warning from the IIS to assess the EMR ability to receive and display the error. |
| Comments |
|---|
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Setup to verify that the EMR is able to receive and display the error response from the IIS. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes |
|---|
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction. |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | Yes |
| Birth Order | 2 |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 10/01/2018 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 10/01/2018 |
| Protection Indicator | Yes |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Elena Gonzales |
| Relationship | Mother |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2018 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Pediarix |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6559FK32 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Document Type | Multiple Vaccines VIS |
| VIS Publication Date | 08/24/2018 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | VFC eligible |
| Vaccine funding source | Private |
| Description |
|---|
The Immunization Registry returns a fatal error message indicating a table mapping error for the CVX code submitted was found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.
|
| Evaluation Criteria |
|---|
The acknowledgement error message is consumed by the system responsible for the content of the administration message. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. This will result in multiple warnings from the IIS to assess the EMR ability to receive and display the error. |
| Comments |
|---|
The Report must include the newly administered vaccine recorded in the EMR. The report may include the information imported from the IIS |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Set up to verify that the EMR is able to receive and display the multiple warning response from the IIS. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes |
|---|
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction. |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | Yes |
| Birth Order | 2 |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 10/01/2018 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 10/01/2018 |
| Protection Indicator | Yes |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Elena Gonzales |
| Relationship | Mother |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2018 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Pediarix |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6559FK32 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Document Type | Multiple Vaccines VIS |
| VIS Publication Date | 08/24/2018 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | VFC eligible |
| Vaccine funding source | Private |
| Description |
|---|
The Immunization Registry returns a warning message indicating an unrecognized administration site code submitted was found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Error Handling Support for a warning returned by the IIS, and the ability of the EMR to display a notification of this warning to the user. |
| Evaluation Criteria |
|---|
The acknowledgement warning message is consumed by the system responsible for the content of the administration message. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. This will result in multiple warnings from the IIS to assess the EMR ability to receive and display the warnings. |
| Comments |
|---|
The Report must include the newly administered vaccine recorded in the EMR. The report may include the information imported from the IIS |
| Pre-condition |
|---|
The vaccines for the visit have been administered. |
| Post-Condition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Set up to verify that the EMR is able to receive and display the multiple warning response from the IIS. Link Standard Codes to Immunization Data: The EHR or other clinical software system links standard codes to discrete data elements associated with an immunization. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes |
|---|
The protection indicator for Juana Maria is 'Yes'. If this setting restricts the EMR from transmitting to the IIS, then the protection indicator for Juana Maria may be modified to 'No' for the purpose of this transaction. |
| Element | Data |
|---|---|
| Patient Name | Juana Maria Gonzales |
| Mother's Maiden Name | Joanna Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 10/01/2018 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race | White |
| Ethnic Group | Hispanic or Latino |
| Multiple Birth Indicator | Yes |
| Birth Order | 2 |
| Element | Data |
|---|---|
| Immunization Registry Status | Active |
| Immunization Registry Status Effective Date | 10/01/2018 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 10/01/2018 |
| Protection Indicator | Yes |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Elena Gonzales |
| Relationship | Mother |
| Address | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Vaccine | Hepatitis B |
| Date/Time Start of Administration | 10/01/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Susan Pike |
| Substance Lot Number | 6332FL432 |
| Substance Expiration Date | 12/14/2018 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Vaccine | Pediarix |
| Date/Time Start of Administration | 10/31/2018 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6559FK32 |
| Substance Expiration Date | 10/31/2019 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | Complete |
| Action Code | Add |
| Route | Intramuscular |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Document Type | Multiple Vaccines VIS |
| VIS Publication Date | 08/24/2018 |
| VIS Presentation Date | 10/31/2018 |
| vaccine fund pgm elig cat | VFC eligible |
| Vaccine funding source | Private |
| Description |
|---|
The Immunization Registry returns a message with multiple warnings indicating unrecognized administration site codes submitted were found during the course of filing the message. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
A VXU message is generated by the EHR. |
| Post-Condition |
|---|
The ACK Z23 is received by the EHR. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. Error Handling Support for multiple warnings returned by the IIS, and the ability of the EMR to display a notification of these warnings to the user. |
| Evaluation Criteria |
|---|
The acknowledgement warning message is consumed by the system responsible for the content of the administration message. |
| Notes |
|---|
Important note regarding the MSH-10 and MSA-2: The NIST acknowledgment message is predefined and is based on the VXU message. Most systems will automatically create the message control Identifier and may require it for importing, linking, and processing the ACK message. The NIST ACK test message can be modified such that MSA-2 matches MSH-10 of the VXU message generated by the system-under test. |
| Element | Data |
|---|---|
| This information will be automatically supplied by the System | |
| Description |
|---|
| Comments |
|---|
| Pre-condition |
|---|
| Post-Condition |
|---|
| Test Objectives |
|---|
| Evaluation Criteria |
|---|
| Notes |
|---|
| Description |
|---|
The provider periodically uses the EMR to identify the cohort of patients that are due or overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
| Post-Condition |
|---|
The Cohort report for all patients that are due or overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
|---|
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
No Note |
| Description |
|---|
The provider periodically uses the EMR to identify the cohort of patients that are due or overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
| Post-Condition |
|---|
The Cohort report for all patients that are due or overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
|---|
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
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| Notes |
|---|
No Note |
| Description |
|---|
| Comments |
|---|
| Pre-condition |
|---|
| Post-Condition |
|---|
| Test Objectives |
|---|
| Evaluation Criteria |
|---|
| Notes |
|---|
| Description |
|---|
The provider reviews the available inventory following vaccine administrations used during the day. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Vaccine inventory entered. Vaccines administered for Juana Mariana Vazquez, Juan Marcel Marina, and Juana Maria Gonzales. |
| Post-Condition |
|---|
Available vaccine inventory displayed. |
| Test Objectives |
|---|
Update Vaccine Inventory from Patient Dosage Administration: The system updates the vaccine inventory to assure the correct count of remaining available vaccine inventory. |
| Evaluation Criteria |
|---|
Evaluation criteria is defined within each test step. |
| Notes |
|---|
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues. |
| Description |
|---|
The provider reviews the available inventory following vaccine administrations used during the day. |
| Comments |
|---|
No Comments |
| Pre-condition |
|---|
Vaccine inventory entered. Vaccines administered for Juana Mariana Vazquez, Juan Marcel Marina, and Juana Maria Gonzales. |
| Post-Condition |
|---|
Available vaccine inventory displayed. |
| Test Objectives |
|---|
Update Vaccine Inventory from Patient Dosage Administration: The system updates the vaccine inventory to assure the correct count of remaining available vaccine inventory. |
| Evaluation Criteria |
|---|
The EMR inventory shows (minimally): 1. Manufacturer: Novartis Vaccines and Diagnostics Ltd NDC:66521-0113-02 Product Name:FLUVIRIN Lot#:8L4B3521 Expiration Date:12/31/2019 Vaccine source:VFC Quantity:24 Syringes (or doses) 2. Manufacturer: Sanofi Pasteur Inc. NDC:49281-0413-58 Product Name:FLUZONE QUADRIVALENT Lot#:D8043IN8422 Expiration Date:12/31/2019 Vaccine source:VFC Quantity:15 Vials (or doses) 3. Manufacturer: Sanofi Pasteur Inc. NDC:49281-0413-58 Product Name:FLUZONE QUADRIVALENT Lot#:D8043IN8855 Expiration Date:12/31/2019 Vaccine source:Non-VFC Quantity:11 Vials (or doses) 4. Manufacturer: GlaxoSmithKline Biologicals SA NDC:58160-0820-43 Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43) Lot#:6332FK18 Expiration Date:6/15/2018 Vaccine source:Non-VFC Quantity:18 Syringes (or doses) 5. Manufacturer: GlaxoSmithKline Biologicals SA NDC:58160-0820-43 Product Name:hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08) ENGERIX-B (NDC 58160-0820-43) Lot#:6332FK26 Expiration Date:12/31/2019 Vaccine source:Non-VFC Quantity:19 Syringes (or doses) 6. Manufacturer: GlaxoSmithKline Biologicals SA NDC:58160-0811-43 Product Name:DTaP-hepatitis B and poliovirus vaccine (CVX 110) Pediarix (NDC 58160-0811-43) Lot#:6559FK32 Expiration Date:12/31/2019 Vaccine source:Non-VFC Quantity:15 Syringes (or doses) |
| Notes |
|---|
This test step is introduced in 2018 and will be considered an evaluation year for the test step. Tester should document feedback and issues. |